~ A periodic blog on matters health, union, social justice, and the occasional random rant

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Three days ago Nick Staikos, the MP for Bentleigh, tweeted about a leaflet his constituents had received – at first glance it could be construed as coming from his office, rather than from Right to Life, and Mr. Staikos did not appreciate the confusion.

This will be a conscience vote, which means each parliamentarian will decide for themselves, ideally based on review of the facts, and reflection on the best interests of the people of Victoria. The seat of Bentleigh is one of a small handful of very marginal seats – over a month ago, the Australian Christian Lobby announced that it would be targeting these seats, and “vowed to derail the legislation and electorally punish MPs who end up supporting it”.

I have no problem with lobbying – those of us who want this legislation passed will also be calling on like-minded people to contact their MPs, will (as I have) write to papers and post things on social media. The key difference, as I see it, is that while the people I’m talking with are very careful to remain accurate, calm, and support our positions with facts, those who think differently appear to be a little less cavalier with the truth.

I was given a pamphlet that, as far as I can tell, differs from the one distributed in Mr. Staikos’s electorate only by the MP details. Let’s take a look at it.

I’ll set aside the fact that Right to Life have created a false binary (in which suicide prevention is antithetical to assisted dying) and note that, not only is this intentionally inflammatory, it falsely conflates suicide (the intentional ending of one’s viable life) with the inevitable death of a person in the end stages of a fatal disease, illness, or condition – in the case of the former, intervention can result in a healthy, happy life; in the latter, the only question is whether the end will be comfortable and on their terms, or tormented.

First of all, the “government-sanctioned suicide” will not be by doctors – except in rare cases, where patients are unable to do so because of physical or digestive reasons, the role of doctors is to assess, advise, refer as appropriate, educate, and (if indicated by the screening process and the patient’s unwavering intent) prescribe. The use of the phrase “sick and inform” is hard to read as anything but intentionally misleading – anyone accessing this legislation must be nearing or at the end of life, from a disease, illness, or condition, and have suffering that not able to be adequately managed, aand be competent, unwavering, and uncoerced.

The question “Is he trying to save healthcare dollars?” is an egregious allegation. While it’s true that people on average consume (for lack of a better word) more health resources in the last twelve months of life than at any other time, that is rarely because of palliative care; far more often it’s because death is fought, with ICU, investigations, expensive imaging, and surgery. I have spoken with doctors, Victoria’s Health Minister, other MP’s, palliative care and hospital administrators, and not once have any of these people mentioned money. More than that, I have cared for patients for over a quarter of a century, in Victoria’s public system; despite the pressure for beds, and KPI’s, and review meetings regarding length of stay, nobody has ever suggested cost as a reason for transferring a patient or changing their care. If the Premier were motivated by that, a) surely he would have brought this up as an option earlier, either pre-election or when he was health minister, and b) his position wouldn’t have changed following his witnessing the dying of his father.

Right to Life end the facing page with equal distortion. We already have world class patient care, improving palliative care resources, and nobody is killing other people. The line “the life you save may be your own” is ridiculous – even in Belgium, where some of the most liberal laws are in place, people are not at risk of being killed against their will. Oregon’s laws are unchanged in two decades, and Victoria’s Bill is even firmer – this is nothing but fearmongery.

Onwards.

Apparently Right to Life are unaware that Britain comprises England, Scotland, and Wales…

It is true that, over time, utilization of these laws increases – as is the case with anything novel, from smart phones to laparoscopic surgery:

“If you legalize on the broad basis (that) the Dutch have, then this increase is what you would expect,” said Penney Lewis, co-director of the Centre of Medical Law and Ethics at King’s College London. “Doctors become more confident in practicing euthanasia and more patients will start asking for it,” she said. “Without a more restrictive system, like what you have in Oregon, you will naturally see an increase.” (source)

In the Netherlands, that increase is from 1.7% of all deaths in 1990 (before the introduction of legislation) to 4.5% in 2015; in Belgium

It is also true that both the Netherlands and Belgium have widened the parameters under which assisted dying may be provided, and that a person who has unbearable suffering without realistic likelihood of improvement meets the criteria, even if that suffering is psychological rather than physical. In the table below, “Underlying illnesses of Dutch assisted dying cases (proportion of all deaths)” (source), those patients are represented in bright blue, and account for some 3% of all assisted deaths in 2015. Cancer, which is the cause of almost a third of all deaths in the Netherlands, also accounts for the overwhelming majority of assisted deaths.

It is utterly untrue that the Oregonian law allows people accessed to assisted dying because they have a mental illness. A person must be:

1) 18 years of age or older,
2) a resident of Oregon,
3) capable of making and communicating health care decisions for him/herself, and
4) diagnosed with a terminal illness that will lead to death within six (6) months. (emphasis added, source).

Absolutely nothing there about mental illness being a reason to access the Act though, as here, having or having had a mental illness does not prevent someone applying, provided they are clinically competent.

Ms. Tighe’s pamphlet also refers to 431 people in the Netherlands whose lives were ended without specific request, and that appears to be accurate – on CBS’s statistical summary dated May 24 of this year, the breakdown of 7, 254 assisted deaths (of a total of 147,134 for the year) includes 431 titled “Levensbeëindigend hand. zonder verzoek” (or ‘assisted, end-of-life, without request’). That’s 0.059% of the 4.9% of Dutch deaths that are assisted, and that figure doesn’t tell us anything about the cases, or prior directives, and as 350 of those cases were patients aged 65 and over (201 of which were over 80), it is fair to assume many involved end-stage dementia.

This is certainly not ideal, but it’s also not applicable to the Victorian situation, where competency is an integral component of the process. It’s a pleasant to change to find a verifiable, accurate fact in this pamphlet, albeit one I suspect is also the worst Ms. Tighe’s organisation was able to find.

Speaking of verifiable facts, when we turn the page we find three cautionary cases from Oregon of women who were either forced into this option, or avoided it and lived happy lives.

As there are no citations, I have had to search for these stories myself.

Ms. Wagner’s case was publicised in 2008 when, after several years of treatment with first and second line chemotherapy, her insurance company refused to pay for an experimental drug that would potentially extend her life from four to six months, as Tarceva did not meet their requirement of 5% survival at 5 years. Indeed, at the time the drug made no significant improvement for 92% of patients, though it did induce rashes, diarrhea, and other unpleasant side effects in 19% of people taking it. Instead they were only prepared to cover palliative and comfort care, which included (but was not restricted to) assisted dying. After the media storm, the drug manufacturer agreed to cover the futile treatment; there are reports that Ms, Wagner died shortly thereafter.

Ms. Packer lives in California, and was anti-assisted dying well before any discussion about treatment funding. She was diagnosed with scleroderma, an autoimmune disease that causes scarring of body tissues, which was treated with chemotherapy; after three years, she entered negotiations with her insurer who, after five months, agreed to cover an alternative treatment, then changed their mind.

Packer then called her insurance company to find out why it wasn’t covered, and in none of the articles, Packer actually tells us why. You’d think that information would be useful in a news article about coverage denial. Instead, while on the phone with her insurer, she asked them if they cover the assisted suicide drugs and they said yes. The insurance company did not “offer to pay for her to kill herself.” (source)

Even if these cases had happened as described, they would not be reason to vote against the Victorian bill – Australia has universal health coverage, the overwhelming majority of people who need end-stage support use public facilities, and our private health insurance is voluntary, and paid by individuals – any company that instituted an policy that disallowed proven treatments with genuine outcomes would be abandoned by members in droves.

Death With Dignity have discussions about these and similar cases presented by groups like Right to Life, though Elizabeth Hall is not one of them. Google searches for “Elizabeth Hall” + “bowel cancer” + “assisted dying” came up with no relevant hits, and searches substituting “assisted suicide” and then “euthanasia” were similarly fruitless. There are insufficient details related on the pamphlet to know if the mysterious Ms. Hall would have met Oregon’s requirement of a six-month (or less) prognosis, but the number of people with end-stage bowel cancer who survive more than five years (let alone 15+) is very low.

What’s my take home message about these pamphlets? They certainly don’t seem to be created with education in mind, or even an argument against assisted dying based on any kind of coherent platform. Instead they have been written to heighten fear and apprehension, with deliberate skewing of the facts, and omission of vital information. If your argument can’t stand in the light, if it must be cloaked in emotion and distortion, then it isn’t robust, it isn’t valid, and it isn’t worth listening to.

One of the objections about assisted dying legislation is that vulnerable people will die, through coercion, because they feel like a burden on their families, for financial gain, or because their care is expensive or onerous. These are valid concerns to have – we know that there are unscrupulous people who take advantage of even their own relatives, that not all health practitioners are wholly ethical, and that there are financial pressures on health facilities at every level. And many of us have heard reports from overseas about people who didn’t meet the criteria being killed under the auspices of assisted dying laws, or weren’t reported to the government. While on closer examination these reports invariably turn out to be distortions or unsubstantiated allegations, a topic I may address at another time, the fear they address is a reasonable one – even if they haven’t happened, they could.

Last week, when I briefly summarised the final report of the voluntary assisted dying expert advisory panel, I mentioned some of the 68 safeguards that are in place. Today I’ll go into detail about the requirements and regulations that will be implemented to prevent this legislation being misused.

The first six safeguards ensure that requesters meet all of these threshold requirements before the process starts. They must:
• be eighteen or older (this law will not apply to minors),
• be resident in Victoria (people can’t travel here to die with assistance),
• be competent to make significant medical decisions (using the same standard the Medical Treatment Act, 2016, requires),
• have a life-limiting condition, illness, or disease (e.g. metastatic cancer, end-stage heart failure, motor neurone disease),
• have a prognosis of twelve months or less (their death is inevitable, and not distant), and
• be ‘experiencing enduring and unbearable suffering that cannot be relieved in a manner the person deems tolerable’ (e.g. for that person it may not be acceptable that the only analgesic dose sufficient to make their pain bearable makes them unconscious),

Note that a person must meet all of these criteria before the process of assessment can begin; in contrast, in the US people do not need to be suffering, while in Europe it isn’t required that they be dying.

The legislation specifically notes that disabilities and mental ill-health are neither barriers to, nor reasons for, voluntary assisted dying. In other words, someone may not access assisted dying because they have, for example, significant cerebral palsy, or are paraplegic, or have clinical depression, or schizophrenia – the requirements for a life-limiting illness, condition, or disease, a terminal prognosis of under a year, and enduring suffering, apply universally. Conversely, people who meet all the other criteria cannot be deemed ineligible because of a physical disability or mental ill-health.

The rest of the safeguards are divided into areas of protection. First are measures to ensure that the request process is voluntary:
• health practitioners are prohibited from bringing up the option of assisted dying with their patients – it must come from them,
• nobody except the person can request on their behalf, even someone with medical power of attorney and an advanced directive demonstrating that this is what they want,
• there must be three requests, over at least ten days, one of which must be written, and witnessed by an independent person, and
• the person can change their mind at any time, including after the prescription has been filled.

Next is the process of assessment, which is clearly and tightly described:
• two independent, experienced medical practitioners must separately assess the person (overseas this typically takes 60-90 minutes per consultation),
• only doctors who have undertaken specialized VAD training may be involved,
• the two assessing doctors are designated the coordinating practitioner and the consulting practitioner, each with well-defined duties, and
• either doctor may, and is obliged to, refer the patient to a mental health professional if they have concerns about the person’s decision-making capacity,

There have been concerns about prescribed medication going missing or being taken accidentally. To that end, the following measures will be introduced:
• the prescribing doctor must have a specific permit,
• the patient must nominate a contact person who agrees to take responsibility for returning the medication to the dispensing pharmacist if it is unused,
• from the time it is dispensed until it is taken or returned, the clearly labelled medication must be stored in a locked box,
• if the patient is unable to self-administer (e.g. is unable to swallow, has restricted arm movement), the coordinating doctor (and only the coordinating doctor) may administer the medication, and
• in that case the doctor must have additional certification, and the administration must be witnessed by someone who is independent of the doctor.

Unsurprisingly, health professionals, particularly doctors and nurses, have concerns about their roles, from being forced to perform acts with which they object, to being prosecuted. To protect them,
• health practitioners may conscientiously object to participating,
• there are protections for health practitioners who are present at the time of administration, and
• health practitioners will be required to report any practitioner acting outside the legislation.

There was a question raised about criminal consequences for health professionals who act outside the scope of the legislation – initiating a discussion about the option of assisted dying, for example. That is not specifically addressed, as there are already consequences for health practitioners who break the law or otherwise act in breach of the standards of each registered profession (one of which includes following the law), and charges of manslaughter and murder are not affected by the introduction of voluntary assisted dying legislation – it is still a crime to aid or to abet a suicide, or bring about someone’s death, except for the carefully delineated circumstances surrounding this Act. There will, however, be new laws introduced: failing to report any step, inducing or influencing a person to request or participate in assisted dying, and falsifying reports to the oversight and review panel will be criminal offences.

Finally, there have been allegations that not all deaths overseas that take place under the auspices of an assisted dying framework are reported or investigated appropriately. In Victoria, part of the process includes the creation of an independent multidisciplinary oversight and review panel. They are notified at every step of the process, from the first formal request to notification of death. Included in this process is notification whenever a prescription written to assist dying is filled. The patient’s contact person is tasked with returning the medication when the patient dies, if it was not used; if they fail to do so, the panel is empowered to follow up with them about the location of the medication, and ensure it is safely accounted for.

The oversight and review panel’s role will be enshrined in legislation, and it will have the capacity to refer breaches of the legislation to the appropriate authorities, from the health regulator AHPRA to the police. The panel will review every case, transparently report publicly, and publish a review after five years.

The expert advisory panel estimates that it will take eighteen months to set up all of the required safeguards (e.g. medical education) and legislative changes, before the first requests can be made.

But first the Bill has to get through both Houses of parliament. Which is where you can come in: if you support the legislation and you live in Victoria, please contact your lower and upper house MP’s to let them know – they can’t represent their constituents if they don’t know what you want.

Over the next couple of weeks I’ll explore some aspects of this comprehensive, 257 page report in greater detail, including one post dedicated to detailing and discussing the 68 safeguards it recommends. Today, though, I’ll just cover the highlights of the final report from an expert committee that comprised representatives from medicine, nursing, health care institutions, the law, disability advocacy, and palliative care.

The biggest take away message is that this will be the most rigid assisted dying legislation passed anywhere, taking all the requirements, oversights, and safeguards used around the world, then adding more.

To start, applicants must meet all of the following requirements:

be aged 18 or over

be resident in Victoria

be competent to make complex medical decisions*

be diagnosed with a terminal/life-limiting illness, disease, or condition

have a prognosis of twelve months or less, and

have suffering that is not able to be relieved

Each element is detailed, from who can initiate discussions about assisted dying (only the patient) to the requirements of the two assessing doctors (one of whom must be qualified in the relevant specialty [e.g. oncology, if the person has metastatic cancer], one of whom must have at least five years’ post Fellowship experience, and both of whom must be fellows of a college, and both must have completed the required VAD training); from the timing and sequences of steps (three separate requests, on in writing, over a period of not less than ten days**) to when a person can change their mind (any time in the process up to and including the point of swallowing the medication); safe keeping of the medication, from a designated contact person who must return dispensed medication if not used, to storage of the drug in a locked box; and oversight, from tracking presented prescriptions to review of all cases by an expert panel, who are reported to at each step of the way.

There are safeguards to ensure that unscrupulous relatives aren’t taking advantage of a vulnerable relative, with requirements both regarding competency (as mentioned earlier), and that witnesses to the person’s written request may not benefit from the person’s death. Similarly, in the event that physician-assistance is required (in rare case where the person either cannot physically pour, hold, and swallow the medication, or lacks the digestive process to safely swallow and absorb the usual oral preparation), there must be a witness independent from the assisting physician, to attest that the patient was willing right to the end.

The most significant aspect, consistent throughout, is that participating is voluntary for every person, at every stage. The requests must be made by the dying person; the assessing doctors have the right to conscientiously object; the nominated contact person must agree to taking responsibility for the medication and other obligations; nurses can choose to conscientiously object to involvement in education or facilitation of the assisted dying; and in the event that the patient needs physician assistance because they are unable to take the medication (either because of physical or digestive incapacity), the coordinating doctor must consent, along with the witness.

This is a rigorous, restrictive, robust document that provides consistent, thorough safeguards, strong review processes, and (in combination with registration requirements from the boards overseeing health professionals) penalties for breaches from and non-compliance with the regulations. Now we just need to get it passed.

* “The Panel considers that the four part decision-making capacity test in the Medical Treatment Planning and Decisions Act should be used to assess an adult’s decision-making capacity in relation to voluntary assisted dying. The Act is contemporary, having been passed in 2016, and is generally regarded as a appropriate to test decision-making capacity for a wide range of medical treatment decisions.” Ministerial Advisory Panel on Voluntary Assisted Dying Final Report, 2017 p. 60

** except in exceptional circumstances, when the person is highly likely to die within the usual waiting period

There are a number of ways that I could approach this perennial issue that rouses strong and often polarising opinions. I have a graduate diploma in bioethics, and a masters in health ethics, so I’m well versed and better qualified than many to take a relatively objective stance and present a robust, solidly-constructed argument based on virtue ethics, Beauchamp and Childress’s Principles, casuist philosophy, or even a Hippocratic perspective. I could present an argument from self, about what I would want, and invoke Mills, who argued that there are limits to the reach of the state over the individual. Or I could, as SA nurse Sandy Bradley has, speak from a professionally dispassionate perspective, with citations and an academic tone.

These are all valid, useful ways to discuss assisted suicide/voluntary euthanasia, and reading these kinds of pieces have informed my position. But what has most strongly strengthened my commitment to the legalisation of assisted suicide isn’t theory, or research, or philosophical argument. It’s the patients I’ve cared for, and those for whom my care was woefully inadequate. The patients whose memories still bring tears to my eyes, a lump to my throat, and a sensory reminder of the frustrated impotence I felt when “everything we can do” wasn’t close to being enough.

I have seen people in kinds of distress I wish I never knew existed, experiencing so much pain it’s been hard to believe it didn’t kill them. The very first person I saw die vomited and retched until the moment she died, despite high doses of antiemetics. I’ve helped a colleague turn a patient whose limbs were so swollen with excess fluid that they wept, constantly, a physical grief reflecting his unending moans. I cared for a frequent flier patient, who I had come to know well over the course of almost a decade, who crawled up the ward corridor crying for pain relief I was forbidden to give her because the doses that would lower her pain would also kill her – she died less than a week later, still in pain. I had to tell the wife of another familiar and dear patient that I couldn’t help him die sooner, though it was what I wanted to be able to do even before she dropped to her knees before me, and begged.

Over a decade ago I heard Roger Magnusson talk about his doctoral research that, in part, described, the kinds of deaths that occurred in the absence of formalized, legalized assistance, and I was horrified by the lack of screening, the lack of dignity, and the effects on everyone involved. Earlier this year, at the ANMF (Vic branch)’s annual delegates conference, I heard Andrew Denton speak about watching his beloved father, Kit, die over an eternity of three days. It reinforced my belief that the time has well and truly come for Australia to join those countries and states that offer their dying and suffering populations another choice at the end of life, if the interventions currently available aren’t enough.

There have been dozens of Bills brought in front of parliaments across the country, with varying degrees of traction, but none with success – in part because there were inadequate safeguards to protect our most vulnerable, but mostly because opposition from organized religion (such as the Australian Christian Lobby) has been better mobilized, and louder; their position may be the minority one, going by every poll on assisted dying, but their voices are disproportionately heard, and that’s neither right nor fair.

I understand concerns about both coercion of people who are influenced by unethical family members, and the fear of a slippery slope to wholesale, state-sanctioned murder; I do not agree either or both are reason to prevent those who are dying, suffering, and beyond the reach of palliative care from having the option of a faster, kinder route to the death their condition makes inevitable. Instead any legislation should be informed by these reasonable concerns, by including rigorous safeguards to protect those at risk of underhand manipulation. I will write at some future point about how the ‘euthanasia’ committed by Nazi Germany in the 1930’s and 1940’s was not only qualitatively unrelated, but also the result of very different motivation; for now, suffice it to say that this is neither a likely nor plausible end point when we start by looking at compassionate, patient-centred, voluntary additional options for competent people who are terminally ill.

A quick last post before I vote.
I first started this blog as a series of posts on the then-ANF’s Facebook page, as a way of maintaining morale through what none of us, mercifully, knew would be months of campaigning. The first post I found, tracking back when I started this blog, was December 9th 2011, when there were 1,086 days to go until Victoria voted – and that was all I wrote. Over time those posts became longer
For me, the way this government treated nurses and midwives during our dispute would be reason enough to vote them out – months of stalled negotiation, of saying one thing to our faces but (as a leaked Cabinet-in-confidence document revealed) plotting to remove ratios, skill mix, and introduce split shifts.
For many nurses and midwives, and certainly for me, the calibre of the current government was revealed when David Davis accused ANMF (Vic. branch) Secretary Lisa Fitzpatrick of blackmailing us into taking industrial action. We we’re at least as incensed by the slur on our respected leader as on the clear insinuation we’d all done something blackmaiÍable.
Nurse withdrew labour, for the first time in a quarter of a century, and only the third time in Victoria’s history.
Not to win. Not for huge pay increases. Just to get into Fair Work, just to force genuine negotiations, just to keep what we had.
And then they did it to fire fighters – while blocking WorkCover access for occupationally-acquired cancers.
And then to teachers.
And, after twenty-six months, paramedics still have no agreement, and no pay increase since 2011.
The premier’s changed, but the tactics haven’t – delay, denigrate (apparently Victoria’s most trusted profession is comprised of “thugs”), dirty tricks, and deceive.
Oh, there’s no money for paramedics, but there’s a massive budget for ads in every Victorian paper, distorting the ‘deal” on offer, without noting little facts, like a generous super package after 30years service having little meaning in a career with an average five year length of service.
Or removal of protected meal breaks, meaning MICA paramedics could work 14 consecutive hours, before factoring in up to an hour drive each way (with new ‘flexible workplace’ clauses) with no break. At all.
Like nurses and midwives, like fire fighters, like teachers, paramedics aren’t just campaigning for themselves and their profession – we’re all on the front line.
We all see what these cuts in numbers, services, support staff and funding mean for our ability to serve the public.
For teachers that means the long term education, employability and wellbeing of students
For paramedics, nurses and midwives, it means physical lives.
For firefighters it means the risk to their lives to save our lives, livestock, and property.
Today I’m voting Labor, because Victoria can’t afford another term of this government.
Because if this is how Victoria’s most trusted professions are treated, how do you think those with least are treated?
And because I believe that the Labor party, under Daniel Andrews, has vision for Victoria – growth, consultation, respect, direction, and integrity.
If you’re one of the 10% unsure how you’ll vote today, please think of this when you cast your ballot.
Vote however you like, but make your vote an informed one, a considered one.
And pay attention to preferences, because the Right’s complex deals have already created a politician out of 0.51% of the primary vote 14 months ago, and they’ve done it again this election.

Many people think they know what nurses do, but there’s more than the tasks you see us perform; what you can’t see is the clinical judgement, the assessments, the constant re-prioritising of needs, so that what can seem really straightforward from the bed is more complicated on the floor. Some of that is inevitable, but some of it is made harder by a system under stress.

I’ve been a registered nurse in Melbourne’s public health system for over twenty years – it’s a job that I love, because I get to make a positive difference to people’s lives every day, often at a time when they’re afraid, in pain, or vulnerable.

Delivering health care has never been easy, but under the Baillieu/Naphine government my job has been more difficult than it needs to be. Every month our hospitals are put under more pressure to increase how quickly we process patients – to get them up to the wards from Emergency within four hours, even if that means they haven’t been adequately assessed, or may not even need admission; and to send patients home as quickly as physically possible, to community health support services that are increasingly stretched.

Those people who need treatment like intravenous antibiotics can, in some cases, now have them at home. Health Minister Davis has counted these patients towards the 800 new hospital beds that his government promised at the last election. But they’re not new beds.

Despite this increasingly demanding, difficult nature of our work, Victoria’s health care system is still productive and efficient, treating more patients without increased resources.

Instead of recognising that more acutely ill, complex patients need more nurses to care for them, the Napthine Government tried to reduce the number and experience of staff caring for the public.

In 2011/12, nurses had to fight harder than we’ve ever needed to before, to ensure our patients only get acute public health care from qualified nurses, not minimally-trained aides nominally under our supervision, and to keep nurse: patient ratios. Before nurse:patient ratios, I would try to care for eight or more complex patients on my own.

We asked for more nurses in emergency departments, to manage the increasing number of patients who need treating every day; we were told that would shorten ambulance turnaround times, and count as a paramedic efficiency gain, but a nursing cost, as though the aim isn’t to have a health care system functioning as a coordinated, effective whole.

And at a time when we need to be investing in aged care services, the Napthine Government has privatised 588 aged care beds, including a specialist facility that had a waiting list for vulnerable aged people with significant mental health concerns.

And there are another 243 aged care beds slated for sale, to private companies whose goal is profit, not people’s health and wellbeing. The burden of their care will fall increasingly on already struggling families, and on to the acute public sector.

Our nursing workforce is now middle aged, and getting older. We have new nurses keen to enter the profession, but funding for graduate year placements has been slashed by the Napthine Government – ending their careers before they’d begun. In one year alone, some 800 Victorian graduates were left with debt, and no options.

Premier Napthine and Health Minister Davis are making a lot of promises about their commitment to health. They’ve had four years to demonstrate that they value health, and the professionals who provide it. In that time Victoria has seen unprecedented elective surgery waiting times, fewer acute care hospital beds, privatised aged care beds, emergency departments struggling to cope, a jump in violence against health providers, and too few new graduates entering the nursing profession to keep it sustainable, let alone attract prospective nurses.

I worry about the kind of health care my colleagues and I will be able to provide under a second term of this government, and I worry about the care my loved ones will receive. Because that’s the thing about the public health sector – if you’re really sick, it’s the only place you can be cared for. And, as so many of my patients have discovered, the next person needing emergency care could be any one of us.

This post was originally published here, as part of the Real Stories campaign – check out stories from other nurses, paramedics, fire fighters, teachers and other people whose ability to perform their work has been negaticely affected by the napthine government

The Abbott government was elected on a raft of lies and broken promises, all of which have the potential to have devastating consequences for many people, predominantly pretty much exclusively those with least to begin with. Not that it’s always easy to tell precisely what the effects are going to be, as even Mr Abbott’s Cabinet seem to be unsure, as evidenced by yesterday’s quick about-face on pursuing HECS debt after death (and The Conversation‘s retraction of how long HECS will take to pay off now course costs and interest will rise, but the payment threshold will drop).

I’ll write about some of the other ‘reforms’ being introduced next week, particularly the targeting of people on Disability Support Pensions. Like my topic for today, that tactic’s come straight from the UK Tory playbook.

In the UK the Conservative government slowly starved the NHS of funds, then turned around and said “see? It doesn’t work!” as an insidious privatising began.

Australia leaped ahead a little there – we’ve started selling off aged care facilities already, with barely a whisper of consultation, let alone publicity (and that, too, I’ll address next week). But today I want to talk about co-payments for GP visits (and allied health consultations, and radiology, and other investigations).

This government has launched a concerted attack on universal health care. It started with a rubbery statistic – that annually, we make an average of eleven GP visits a year. That sounds like a lot to most people, and when uttered hand-in-hand with insinuations and outright claims that ‘some people’ (predominantly over-anxious mums, and the isolated elderly) are going ‘too often’ makes it seem reasonable for a tokenistic disincentive to ease the strain on our struggling public system.

Only none of it was actually true. On average, Australians see a health care practitioner who bulk-bills all or a portion of the visit eleven times a year, true – GP’s comprise about half of that, with the remaining visits going to physiotherapists, occupational therapists, dieticians, speech pathologists, diabetes educators, clinical nurse practitioners, and the like.

There are undoubtedly some GP visits that are unnecessary – after the fact, because often it’s not possible to tell if the issue’s significant or not; laypeople aren’t doctors. And even if you know that what you’ve got doesn’t require medical attention, many visits are for mandatory medical certificates for time off work or school.

But, says Mr Abbott, we don’t value what we get for free – a small impost, the cost of a cup of coffee, a sandwich, a couple of middies, is enough to make malingerers stop, think, appreciate what they’re getting.

Only here’s the thing – we already pay for Medicare. There’s a specific levy for it. And while it’s true that the levy’s 1.5% (plus an additional 1% if, like me, when you earn over the threshold you choose to support universal health care instead of private insurers), and Medicare costs 9% of GDP, that’s been the case since 1997.

Oh, but Medicare’s unsustainable, and so we have to pay more toward it.

Except that (despite cutting CSIRO funding to the bone, including the agencies that take research from the lab to the market, where we can make money – an area where Australia lags sadly behind most countries) we need the money to fund an enormous medical research centre. Not now, but in the future, when the funding comes in. Because that means we won’t need to spend so much on health care…

Our health care system is robust, cost-effective, and it delivers. It’s not perfect, but its imperfections are predominantly in under-servicing rural and remote areas, under-funding aged care and mental health, inadequate preventative interventions, and too much emphasis on sexy, expensive, acute care.

Amazing NSW nurse Kerry Rodgers on QandA

Here’s the reality – if you want to cut health care costs, general practitioners are not the place to look. They are one of the most cost-effective parts of our system. Good GP’s save money, and lives – prompt action means that many acute issues can be treated before they worsen, and chronic conditions are managed before they become life-threatening.

We don’t have figures on how much a hospital bed costs per day, before medications and interventions (though we do for aged care),so I can’t say how much an outpatient treatment of cellulitis through a course of oral antibiotics compares to inpatient admission for five to seven days, with intravenous antibiotics. I can tell you that it’s easily a hundred times more, based on the cost of the drugs and administration alone.

I can tell you with certainty that giving pneumovax or Fluvax to someone at risk costs a fraction of treating them for pneumonia or the ‘flu – and that, having had both, you’re looking at weeks of time off work as well as direct health care costs. That’s bad from a productivity perspective, disastrous if you’re one of the 40% of our work force on casual or contract work.

Poorly controlled diabetes causes multiple irreversible complications that mean anything from admissions for amputation, to dialysis – we know that the best, and least expensive, way to avoid that is regular education, supervision and support, including annual eye exams, bi-annual podiatry, lab bloods, and consultations with a specialist team of endocrinologists, dieticians and diabetes educators working with the client, family and GP.

That’s just three conditions, off the top of my head. As a nation, GPs are cost-effective. For those who are already struggling to make ends meet, Mr Abbott’s ‘small impost’, Ms Bishop’s sandwich, Mr Hockey’s middies or a third of a packet of smokes is the worst kind of disincentive.

These are people who’ve never had to decide between utilities and rent; between school shoes or dinner; who’ve never wept at a parking fine or rent increase. If you’ve never felt your heart leap at the discovery of $5, if a bought sandwich is an everyday occurrence and not a rare treat, you don’t get to decide that $7 isn’t much.

We know what will happen as a result of this move: those who most need early intervention will delay seeing a doctor, and present at emergency departments far sicker than they need to be, which means more cost for the system, and a lot more pain, suffering, risk, and potential economic consequences for them and their families.

Those who are on disability or aged pensions and have multiple medications will reduce their doses to eke out their drugs; fewer infants and children will be immunised; Pap smear and prostate exams will fall; annual wellness checks will be skipped.

And in the short term there won’t be an effect. But it won’t take long – and I mean months – before we start seeing the real damage, in human and fiscal costs.

We know this is a government that creates policies of myopia, that is incapable of long-term or big picture thinking. And we know that it’s a lot harder to reinstate a service or good than it is to retain it in the first place.

The time to act is now. Let your MP know that you don’t support co-payments. Write to the media, ring call back radio, tweet and post and shout it.

And if you’re in Melbourne, and you’re reading this today, join thousands of health care professionals and concerned citizens as we march for Medicare!

In every developed country, the nursing workforce is aging – in Australia, over half of all nurses are aged 45 or older, and there’s a predicted critical shortfall less than a decade away.

Although this is well known, our government is not addressing the issue – though more students are being accepted into nursing degree programs (including Masters-level courses for applicants with an undergraduate degree in another discipline), funding for an intern-like graduate year has been slashed. This is a national problem, but Victoria has the highest number of placement shortfalls – last year over 800 graduates were left without a program placement (something I’ve touched on previously).

Like all degrees, nursing and midwifery are subsidised by the government – student fees only pay part of the course delivery cost. Yet, after investing tens of thousands of dollars in each graduate, the governments in every state are funding fewer graduate positions for nurses and midwives. Though not mandatory, without a graduate year it becomes increasingly difficult for inexperienced nurses to find even casual work, and it’s even harder for new midwives.

Instead of investing in local graduates, we’re filling shortfalls with 457 visa holders.

In the short-term, graduate year programs are expensive – newly-qualified nurses need supervision, including supernumerary time with a more experienced nurse, and have paid study days. Importing nurses who don’t need that investment looks economically advantageous.

And, though employment conditions are the same regardless of origin, nurses on 457 visas are less likely to know their rights and entitlements, or to take action if those rights and entitlements are curtailed – in all industries there are cases of 457 visa holders being under-paid, assigned longer hours, heavier work loads, and less leave time than they’re entitled to. There’s valid concern that any kind of protest, or even query, will see their visa revoked.

Failing to invest in our own graduates harms our profession, and our public. We cannot staff our hospitals solely with experienced local nurses supplemented by overseas-trained nurses – there aren’t enough, for a start. There will be decreasing incentive for students to study nursing or midwifery in Australia if they know that the odds of them then being able to work are lower every year. And without the equivalent of three months of full-time work, they’re ineligible to re-register, meaning every year Australia is losing hundreds of the next generation of nurses and dozens of midwives – nurses and midwives whose education we’ve already paid for.

We all benefit from the experience and perspectives of nurses and midwives from overseas, and many Australian nurses spend a few years overseas, particularly in the UK; reciprocity’s fair.

457 visas are appropriate when there’s no local skill; when it comes to nursing, midwifery, and many other industries, we have the people – we just don’t have a government prepared to invest in them.

It doesn’t matter whether it’s Australia, the US, or the UK – conservative governments care first and foremost about cutting jobs, privatising services, and benefiting business, regardless of the cost.

In London, Mayor Boris Johnson has closed ten fire stations, in seven boroughs. over the objections of nine out of thirteen local councillors, and untold work by fire fighters and community activists protesting the closures.

As I’ve written previously, I had the privilege in September of supporting members of the London Fire Brigade Union as they protested the decision at a London Council meeting. London’s population is projected to increase by 1.5 million people in five years, and most of them will be living in high density housing, in under-served communities – where (shocking!) the greatest numbers of closures have occurred.

Kelly Macmillan’s the first fire fighter I met in London – she generously explained the issues, introduced me to her colleagues, and assisted me to enter the council meeting. Some twelve hours ago she posted this clip on Facebook, by a London taxi driver well-known for his YouTube-published opinions. His language is not safe for work, but it’s not a mile away from that used by emergency and essential service workers, and nurses, and it’s resonant of the frustration I know she, and I, share.

I wish this passion was more common – in the UK, and here. Some of the issues in Australia are different – our fire fighters have bush fires and ludicrous heat to fight, too. But the Tory attacks on essential services are no less vicious, or dangerous. What we’ve seen so far is only the beginning.

This isn’t a fight for our firies, or our paramedics, or the SES – it’s a fight that affects all of us. Any of us could need any (or many) or our emergency services, at any time. Going in to one of our worst fire seasons on record – for NSW the season’s already well underway – every Australian should know how important adequately funding emergency services are.

Last July paramedics saved my father’s life – by the time he hit the operating table he was, his surgeon told me, half an hour away from having bled to death. Almost every day of my professional life I care for people whose lives have been saved by the intelligent, educated, well-trained skills of Victoria’s paramedics. When I worked in burns, and road trauma, and emergency, I know those men and women worked in collaboration with CFA, SES, police officers and fire fighters. I know, on both professional and personal levels, the real, priceless, irreplaceable value of the services they provide.

Maybe politicians don’t. Maybe for politicians, this really is about balance sheets.

But, as the man says, “ultimately it’s the public that allows this to happen.” We know politicians care about votes, especially in Victoria, where we’re only eleven months and change out from an election.

We can make a difference – and we have to. Be informed, be an activist, and be angry. Please.

12 years ago today America suffered its worst terrorist attack; images from that day have become iconic, and many of those features fire fighters – 341 fire fighters died, along with two of FDNY’s paramedics, 60 police officers and 8 private paramedics and emergency medical technicians.

There’s no question that our emergency services workers risk their lives to save not only our lives but our property, assets, flora and fauna – my September 11 post last year recognised that, but it can’t be acknowledged enough. As I type NSW fire fighters are battling blazes around Sydney, as the bush fire season starts some two months early. It’s been a warm, dry winter – there’s more to come.

I’ve written before about the Liberal Premiers’ attacks on fire fighters (here and here in particular) – on funding, staffing, equipment, and on resources for volunteers in rural areas.

I was surprised and dismayed – more than I ought to have been, in retrospect – to discover that the same thing’s happening in London: a Tory politician (in this case London Mayor Boris Johnson) has decided London’s over-supplied with fire stations and, over the protests of a majority of Borough Councillors, is about to exert mayoral privilege to overrule them and close approximately ten per cent of London’s fire stations. You’ll be shocked to learn that many of these are in the least wealthy trusts (the British version of local counsel districts), even though they have the highest density of population.

I heard about a protest being organised by London fire fighters, who’ve spent the last twelve months campaigning against the closures, and decided to join them. I was fortunate enough to meet Kelly Macmillan, a fire fighter and member of the Fire Brigades Union – she was sitting in a truck blaring “Burning Ring Of Fire” and was very helpful in giving me some background.

There were many more FBU members present, but they wouldn’t clump together in a conveniently snappable bunch

Perhaps fifty fire fighters attended the Mayor’s question time, along with members of the press, the public – and one Aussie nurse.I apologise for any terms I get wrong – I don’t know as much as I ought to about my own local government, let alone Britain’s. The horseshoe is Borough Councillors; the desk at the top is the Mayor, Boris Johnson – a Conservative who vowed, when he ran for office in 2008, that he wouldn’t cut services. he says today that the closures would make the Brigade more efficient – a wonderful example of conservative arithmetic that I’ve seen at home: somehow fewer workes with fewer resources become more productive, irrespective of how much productivity’s already improved.

London Mayor Boris Johnson

Unlike Parliamentary question time at home, the gallery interjected strenuously, and though there were requests they be quiet, nobody was evicted. Mayor Johnson became increasingly flustered during the proceedings, rumpling his hair, fiddling with his sleeves, and became increasingly short with those who disagreed with him – twice he expressed outrage at Councillors from his own party, who selfishly put the needs of their constituents ahead of party unity, and at one point he told an official to get stuffed. It’s not Paul Keating-worthy, I grant you, but he never seemed to insult from a position of pressure.

Major Johnson’s arguments will be familiar to us all – he says that regional areas are closing fire houses, that deaths from house fires are dropping, that there will be no forced redundancies, and that there isn’t inexhaustable funding. I like that last point – when was the golden age where financial decisions weren’t needed?

The FBU says deaths may be dropping overall but have increased in high risk areas, some of which are affected by the closures; that the population of London’s projected to increase by 1.5 million by 2018, with no plan to increase services; and that the FDNY, which services a city with roughly the same population in terms of numbers and density, has twice as many fire fighters as the London Fire Brigade. They also point out that Mayor Johnson reallocated funding that should have gone to the fire service to police.

My favourite point was made by a Councillor – in response to Mayor Johnson’s observation that regional centres are closing fire stations, he pointed out that they’re also cutting police numbers; would the major, who’s run strong campaigns on the need for a visible and significant police force, look at reducing their numbers and funding next year? The applause was loud and sustained. This,incidentally, is at a time when at lest one regional area’s recommending Police Chiefs run the fire brigade (link), and Scotland’s already decided to merge the two services.

Here’s what isn’t mentioned – those fire houses occupy valuable land. They’ll be sold, turned into housing – often high density – and when there’s a need to increase services it won’t be viable to purchase or built on land. We’ve seen it happen, in the UK and Australia, with schools – London now faces such a crisis in school places that there are suggestions for three day week programs, or split shifts – I can imagine the joy with which my colleagues in education would greet this, and suspect English teachers are no different.

I close with two observations, after comparing the UK and Australian situations at some length. First – the UK shows us the future, unless we’re very careful. The Tories have been dismantling the NHS by stealth, so that care is now markedly different depending where you live – that’s not universal health care. Wherever there’s a profit to be made, however short sighted and short term, whatever the cost borne by society, they’re for it if it boosts the bottom line. now that we, too, have a conservative government – led by a man who seems incapable of seeing to the end of some sentences, let alone a time frame past a year – we have to be more vigilant and united than ever before.

Which brings me to my second observation – I already knew this, but it’s always worth reinforcing, because it’s easy to lose sight of: whatever differences there are between us, more binds workers together. Whatever our industry, our nation, our skills and our unique issues (like ratios and skill mix for Victorian nurses and midwives), this is clear – we have to act together or fall apart. This holds in individual workplaces (a manager who bends or breaks conditions because she knows nobody will stand up), companies (the introduction of disadvantageous changes), in mass action (like EBA negotiations), and when we’re attacked en masse (like WorkChoices).

We have the power, we just have to recognise it, and use it. Though only 18% of Australian workers are union members, there are still more of us than them – and the more of us who are informed, involved and committed the better off we all are. If you’re not a union member there really has never been a better time to join than today; if you’re already a member of your union bravo! – now look at how you can contribute beyond just your membership fees.

As I’ll be writing about in a couple of days, your union isn’t a building in the city, it’s not elected officials, and it’s not the staff – a union is its members, and it’s only as strong as they, as we, are prepared to be.

Solidarity to my fire fighting colleagues, at home and abroad, and best of luck with your mission to protect your selves, your colleagues and the public.